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SYB: Defecogram
By Borko Kereshi, MSIII
The Case
• 32 year old female with a history of:– Chronic constipation– Straining– Irritable Bowel Syndrome
Defecogram: The Technique
• Approximately 1 hour before the study the patient ingests one bottle of thin barium to visualize the small bowel for possible enterocele.
• Barium paste is instilled into the rectum. • A small metallic marker is placed on the skin
near the anus. • The patient is imaged in the lateral projection
during the following maneuvers…
The 7 Steps of a Defecogram
• 1: Rest• 2: Cough• 3: Squeeze• 4: Valsalva• 5: Evacuation• 6: Post-evacuation valsalva• 7: Post-evacuation rest
Rest
Cough
no incontinence during coughing
Squeeze
appropriate motion of the anorectal angle during the squeeze
Valsalva
appropriate motion of the anorectal angle during the valsalva maneuver
Evacuation
Evacuation
Any abnormalities noted?
Evacuation
Any abnormalities noted?
Anterior Rectocele
Evacuation
Any other abnormalities noted?
Evacuation
Puborectalis Dyskinesia
• contraction of the puborectalis during evacuation (left arrow in preceding image)
• Additionally, there is contraction of the anal sphincter during evacuation consistent with sphincter dyskinesia (right arrow)
Post-evacuation valsalva
Post-evacuation rest
Small post void residual
• The patient required multiple efforts of Valsalva and squeeze to evacuate the barium.
• This impaired contraction is highly predictive of anismus– Anismus: malfunction of the external anal
sphincter and puborectalis muscle during defecation
– More common in women– Sometimes associated with sexual abuse
References
• LEROI A.-M. ; BERKELMANS I. ; DENIS P. ; HEMOND M. ; DEVROEDE G. Anismus as marker of sexual abuse : consequences of abuse on anorectal motility. Digestive diseases and sciences. ISSN 0163-2116. vol. 40, no7, pp. 1411-1416, 1995
• healthlibrary.epnet.com• www.aboutincontinence.org